reporting of events to
the appropriate man-
agers and administra-
tions, so they can
address the issue with-
in 24 hours.
3. Review and reevalu-
ate. On paper, no one
did anything wrong
when our near miss
occurred. That was an
eye-opening reminder
of why you need to
constantly reevaluate
your policies and pro-
cedures to ensure your staff is doing everything they can to lower the
risk of inadvertent errors. Don't wait for something to go terribly wrong
before making needed process improvements. Have several leaders
from the surgical unit sit on a committee that reviews your policies and
procedures annually. Every error and near miss is a learning opportuni-
ty, so perform a root cause analysis as an interdisciplinary group on
reported events, no matter how minor the mistake might seem. When
that deep dive identifies the systemic cause of the event, develop a cor-
rective plan that's agreed upon, actionable and monitored.
4. Limit distractions. The OR is a complex work environment where
surgical team members conduct several medication handoffs amid
numerous distractions: equipment noise, multiple conversations going
on at once, outside interruptions and the surgeon's favorite music
1 3 0 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • A P R I L 2 0 1 7
• CONSTANT COMMUNICATION Circulating nurses and surgical techs must identify and con-
firm all medications that reach the sterile field.
Catherine
Dutton,
MSN,
RN,
CNOR
